02/03/12





LTC Perspective

Nearly one in five patients with advanced cognitive and functional impairment who are in their final days of life is subjected to a burdensome, potentially unnecessary transition in health care, such as being moved from a nursing home to a hospital, according to a report in the New England Journal of Medicine.

The frequency of such transitions varies widely between regions of the United States, with rates as high as 37% of the cognitively impaired decedents (in Louisiana), and appears to be increasing, said Pedro Gozalo, PhD, of the program in public health at Brown University, Providence, R.I., and his associates.

Rates of "burdensome" transitions at end of life were as high as 37%.

The transfer itself can be traumatic for these easily confused and physically frail patients, and it opens the door to fragmentation of care and medical errors, said the researchers. Once hospitalized, many such people near death are subjected to further disturbances such as insertion of feeding tubes or transfer to an intensive care unit. However, hospitalization is usually avoidable in patients with advanced dementia because most of the medical problems that arise at the end of life are predictable and “can be treated with equal efficacy in the nursing home,” the investigators said.

They examined Medicare data covering all nursing home residents in the United States and defined “burdensome transitions” according to interviews with families and the expert opinions of geriatricians and palliative medicine specialists. Such transitions thus included transfers during the last 90 days of life from a nursing home to a hospital, transfers from a nursing home to a hospital and on to a different nursing home, and multiple hospitalizations.

The researchers retrospectively identified 474,829 nursing home residents with advanced dementia who were in their last 120 days of life in 2000-2007. Their mean age was 86 years.

A total of 90,228 of these people (19%) had at least one burdensome transition during their final 90 days of life. This included more than 55,000 who were transferred within hours of their deaths, nearly 13,000 who were transferred from one nursing home to a hospital and then to another nursing home, and more than 38,000 who were hospitalized multiple times, the researchers reported (New Engl. J. Med. 2011;365:1212-21; http:// www.nejm.org/doi/full/10.1056/ NEJMsa1100347).

Transitions were more common among black and Hispanic patients than whites, among men than women, and among patients who had no advance directive than among those who did.

The authors said that financial incentives probably underlie many of the burdensome transitions. “Hospitalization generally qualifies a nursing home resident with Medicaid coverage to receive Medicare payments for skilled services, which reimburse the nursing home at a higher rate. In addition, states’ Medicaid payment rates and bed-holding policies that pay nursing homes to keep a bed open for hospitalized residents are associated with increased rates of hospitalization.

“These financial incentives probably result in health care transitions that contribute not only to excessive costs but also to a poorer quality of end-of- life care,” the investigators said.

“Ultimately, a decline in burdensome transitions will come about through a combination of improved provider incentives and decision making that elicits and respects the choices of patients,” they said.

This study was supported by the National Institute on Aging.


Mary Ann Moon is a freelance writer based in Clarksburg, Md.

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